A Centre for Ethics and Social Research, Teaching & Engagement

harms

It was not long ago that the Abbott government vowed to champion free speech, pledging to amend Section 18C of the Racial Discrimination Act, a section of the act that made almost completely useless speech illegal. This commitment was re-affirmed a number of times, including again in early 2015 after the Charlie Hebdo massacre. It seems however the government’s commitment to free speech is largely selective, actively working to keep the marginalised and powerless out of the debate, happy to gag and attack those who dissent.

The recently introduced Border Force Act has raised the ire of a number of individuals and professional bodies, gaining significant media attention with a possible two year prison sentence for speaking about the conditions in immigration detention. Much has been said about how this will impact on the ability of health professionals to report abuse and advocate for patients, however less has been said about how this will only further silence those who are genuinely voiceless.

Silencing the Silenced

The stories we hear from within detention centres are often told through third parties, with many former employees feeling compelled to speak on behalf of those who could not. For all the noise surrounding immigration detention policies, how many of those voices are refugees or asylum seekers?
Hannah Arendt explored this powerlessness in The Origins of Totalitarianism, she argued that even though human rights are proclaimed to be universal, asylum seekers and stateless persons were left with nothing to protect their rights, effectively in limbo, no longer a member of a community where their rights could be enforced. This precarious situation has often been referred to as “the right to have rights”.

“… but it turned out that the moment human beings lacked their own government and had to fall back upon their minimum rights, no authority was left to protect them and no institution was willing to guarantee them.”

She emphasised how this stripped away the right to make oneself heard and opinions matter.

“The fundamental deprivation of human rights is manifested first and above all in the deprivation of a place in the world which makes opinions significant and actions effective… They are deprived, not of the right to freedom, but of the right to action; not of the right to think whatever they please, but of the right to have an opinion”

Managing and processing the powerless

Immigration detention in Australia compounds this powerlessness by further limiting asylum seekers ability to control their own lives and speak candidly about their circumstances. Andre Dao reminds us that this powerlessness can manifest in asylum seekers gambling on their bodies, a symbolic way to regain some control, to be heard. As Dao puts it “you are no longer a human being with free will. Instead, you’re a problem to be managed, an object to be processed.” Few better statements sum this up than these words recalled by an ex-detainee on a hunger strike who was being spoken to by a department employee.

“You understand that your life is in our hands. Your death is also in our hands because we won’t let you die.”

Although a number of asylum seekers have spoken out over the years, their voices rarely make it to the mainstream. Furthermore there remains the expectation of silence both during and after detention, it is not until permanent residency has been gained and families reunited that many feel safe to speak about their experiences.

Silenced subjects and misinformation

Maintaining this silence is key to maintaining our current approach to asylum seekers. The system has been built around rhetoric and misinformation, from children overboard to the present day. Most people can bark back three word slogans, but fewer could tell you what percentage of the world’s asylum seekers arrive on our shores or begin to explain the trauma and torture many have faced before finding safety.

The voices we most need in our debates around asylum seeker policy in Australia are absent, not only that, they are actively excluded. So as well as threatening professionals with gaol time, the Border Force Act only further ensures that that we never get to hear these stories, it ensures that we don’t know who we are locking up or for what reason.

It’s not obvious how the Border Force Act serves to “stop the boats” or “smash the people smugglers business model”, taking into account the boats stopped a long time ago. In attempting to justify this legislation however, the rhetoric has boiled down to a very familiar means justifying the ends rationale, something we should all be careful of and something where it seems appropriate to leave the last words with Hannah Arendt.

“The crimes against human rights, which have become a speciality of totalitarian regimes, can always be justified by the pretext that right is equivalent to being good or useful for the whole in distinction to its parts.”

Many doctors will recall as a student or trainee hanging nervously off the end of a Deaver – a large retractor used in pre-keyhole gall bladder surgery – while simultaneously trying to answer the surgeon’s barked questions about the anatomy in the cavity. The problem is you can’t actually see into the cavity without loosening your grip. A looser grip means less vision for the surgeon and usually a torrent of abuse for the trainee.

Within this mythology, medicine has built a hierarchical and autocratic workplace culture in which incivility, and even frank bullying, towards subordinates is commonplace. Medical students gradually acculturate to this during their training, often at the cost of their empathy and compassion.

A recent meta-analysis of 51 studies on harassment and discrimination in medical training showed 59.4% of medical trainees had experienced at least one form of these. Another Australian study across two medical schools found “teaching by humiliation” – regarded by some as a kind of necessary hardening experience – was experienced by 74% of students and witnessed by 84%. Many still felt the sting decades later.

Such power-oriented, stratified workplaces are good for no one. And, in medicine, many of the worst consequences fall on patients.

The National Health and Medical Research Council (NHMRC) recently completed a review of the evidence for homeopathy’s effectiveness and, after analysing systematic reviews of clinical trials, concluded there was “no reliable evidence for homeopathy and that it cannot demonstrate efficacy.”

To judge the efficacy, and hence the value, of homeopathy on the basis of randomised controlled trials misses the point. Such trials are the gold standard for conventional drugs because they test a medication’s effect across a population, eliminating placebo effects and other forms of perception bias.

But – and here’s the crux – homeopathic medicines are not drugs and homeopathy involves much more than the use of a particular therapy. People don’t visit a homeopath wanting a drug, in fact they often quite deliberately don’t want one; they want individualised treatment.

A randomised controlled trial will tell you exactly nothing about an individual’s experience of a drug. Whereas homeopathy (in which medicines often play a relatively minor role in a complex regimen of care that may include lifestyle modification, diet, exercise and critical self-reflection) is aimed explicitly at how illness is unique to a particular body, experience, and history.

Randomised controlled trial evidence in support of homeopathy is clearly weak. But there are other valid forms of evidence, largely excluded from the NHMRC report, including case studies, patient reports of satisfaction and quality of life, and observational studies. Here, homeopathy does much better.

And while it’s true these studies cannot eliminate the placebo effect and other forms of perception bias, that may also be in homeopathy’s favour. To understand this, we need to consider why people consult homeopaths. Continue reading →

OVERDIAGNOSIS EPIDEMIC – Today, Stacy Carter presents a philosophical view of over-diagnosis and what can be done to change how things stand.

Recently a friend told me a story about her dad. Fit and well, he had a PSA test during a general medical check-up. The PSA test is controversial: many, including its inventor, say it should never be used to screen for cancer.

My friend’s dad’s PSA test started him on a path to prostate cancer diagnosis and surgery. The surgery made him incontinent. Humiliated by accidents, he couldn’t be far from a toilet so could no longer coach soccer or go on his daily long walk with friends. He became socially isolated and sedentary. He put on weight. And he developed diabetes.

Now his health is worse, but it’s not only his health that has been affected. Other aspects of his well-being – attachment to his friends and the ability to live the life he wants – have been undermined. His story is, sadly, not unusual, except for one thing.

The hospital where he was treated called him in to apologise for operating unnecessarily and harming him. Both he and his clinicians concede he was over-diagnosed (the disease would not have produced symptoms or shortened his life) and over-treated (he received treatment he didn’t need.)